Towards the idea of 'clinical capital': A longitudinal study exploring nurses' dispositions and workplace manifestations in an Australian intensive care unit.

OBJECTIVE: To explore the concept of 'capital' through the study of successive interventions and outcomes (patient and staff) in a quaternity intensive care unit (ICU) across a 5-year time frame. DESIGN: A longitudinal intrinsic single site, a survey study was designed. The concept of 'capital' was explored through an adopted interpretive approach that involved understanding meanings from different sources, for example, discussions at compassion cafés, follow-up from staff-initiated activities, informal responses to organizational imperatives external to the unit (i.e. staff reductions and resource constraints), alongside empirical data about workplace climate and patient incidents. SETTING: A single ICU employing approximately 220 registered nurses at a quaternary hospital in Queensland, Australia. PARTICIPANTS: All nurses employed in the ICU at the time of compassion cafes participated in providing feedback to inform successive activities. All nurses in the unit had equal opportunity to complete surveys, participate in subsequent unit-based sessions, take-up options; and all nurses had a responsibility to complete incident data. RESULTS: Survey and incident data from 2015 to 2019 identify the complexity of workplace environments. Between 35% and 45% of nurses consistently completed the survey. Activities based on staff requests initially improved incident data but did not impact the work environment; negative perceptions of the work environment at the endpoint (2019) were associated with external factors. CONCLUSION: Quality care environments are labile; sensitive to both unit activity and external organization directives (namely staff reductions). Quality care can be sustained in adverse situations with increased nurse engagement in patient care dynamics in the short term. IMPACT: This study articulates a previously unidentified concept, 'clinical capital'. Activities facilitating nurse engagement in broad care dynamics gave rise to a more robust climate than just focusing on social and psychological well-being activities for nurses. Participation in issues of concern about patient care can promote resilience to short term fluctuations.

Factors associated with non-beneficial treatments in end of life hospital admissions: a multicentre retrospective cohort study in Australia.

OBJECTIVE: To quantitatively assess the factors associated with non-beneficial treatments (NBTs) in hospital admissions at the end of life. DESIGN: Retrospective multicentre cohort study. SETTING: Three large, metropolitan tertiary hospitals in Australia. PARTICIPANTS: 831 adult patients who died as inpatients following admission to the study hospitals over a 6-month period in 2012. MAIN OUTCOME MEASURES: Odds ratios (ORs) of NBT derived from logistic regression models. RESULTS: Overall, 103 (12.4%) admissions involved NBTs. Admissions that involved conflict within a patient's family (OR 8.9, 95% CI 4.1 to 18.9) or conflict within the medical team (OR 6.5, 95% CI 2.4 to 17.8) had the strongest associations with NBTs in the all subsets regression model. A positive association was observed in older patients, with each 10-year increment in age increasing the likelihood of NBT by approximately 50% (OR 1.5, 95% CI 1.2 to 1.9). There was also a statistically significant hospital effect. CONCLUSIONS: This paper presents the first statistical modelling results to assess the factors associated with NBT in hospital, beyond an intensive care setting. Our findings highlight potential areas for intervention to reduce the likelihood of NBTs.

Doctors' perceptions of how resource limitations relate to futility in end-of-life decision making: a qualitative analysis.

OBJECTIVE: To increase knowledge of how doctors perceive futile treatments and scarcity of resources at the end of life. In particular, their perceptions about whether and how resource limitations influence end-of-life decision making. This study builds on previous work that found some doctors include resource limitations in their understanding of the concept of futility. SETTING: Three tertiary hospitals in metropolitan Brisbane, Australia. DESIGN: Qualitative study using in-depth, semistructured, face-to-face interviews. Ninety-six doctors were interviewed in 11 medical specialties. Transcripts of the interviews were analysed using thematic analysis. RESULTS: Doctors' perceptions of whether resource limitations were relevant to their practice varied, and doctors were more comfortable with explicit rather than implicit rationing. Several doctors incorporated resource limitations into their definition of futility. For some, availability of resources was one factor of many in assessing futility, secondary to patient considerations, but a few doctors indicated that the concept of futility concealed rationing. Doctors experienced moral distress due to the resource implications of providing futile treatment and the lack of administrative supports for bedside rationing. CONCLUSIONS: Doctors' ability to distinguish between futility and rationing would be enhanced through regulatory support for explicit rationing and strategies to support doctors' role in rationing at the bedside. Medical policies should address the distinction between resource limitations and futility to promote legitimacy in end-of-life decision making.

The Role of the Nurse Educator in Sustaining Compassion in the Workplace: A Case Study From an Intensive Care Unit.

Intensive care unit (ICU) nurses are frequently exposed to emotional and stressful situations in the workplace, which has changed little over the decades. Compassion fatigue is caused by sustained exposure to situations that conflict with one's values and beliefs in the ICU, eroding clinical team relationships and ultimately the quality and safety of patient care. Continuing education in the intensive care setting is a priority, as ICU nurses need to remain abreast of the rapid developments in high-acuity care delivery; however, attention also needs to be directed to nurses' emotional well-being. Nurse educators are well positioned to create and sustain open dialogue that contributes to group cohesion and assists nurses' well-being. J Contin Educ Nurs. 2018;49(5):221-224.

Ethical responsibilities of pharmacists when selling complementary medicines: a systematic review.

OBJECTIVE: The widespread sale of complementary medicines in community pharmacy raises important questions regarding the responsibilities of pharmacists when selling complementary medicines. This study reviews the academic literature that explores a pharmacist's responsibilities when selling complementary medicines. METHODS: International Pharmaceutical Abstracts, Embase, PubMed, Cinahl, PsycINFO and Philosopher's index databases were searched for articles written in English and published between 1995 and 2017. Empirical studies discussing pharmacists' practices or perceptions, consumers' expectations and normative studies discussing ethical perspectives or proposing ethical frameworks related to pharmacists' responsibilities in selling complementary medicines were included in the review. KEY FINDINGS: Fifty-eight studies met the inclusion criteria. The majority of the studies discussing the responsibilities of pharmacists selling complementary medicines had an empirical focus. Pharmacists and consumers identified counselling and ensuring safe use of complementary medicines as the primary responsibilities of pharmacists. No formal ethical framework is explicitly employed to describe the responsibilities of pharmacists selling complementary medicines. To the degree any ethical framework is employed, a number of papers implicitly rely on principlism. The studies discussing the ethical perspectives of selling complementary medicines mainly describe the ethical conflict between a pharmacist's business and health professional role. No attempt is made to provide guidance on appropriate ways to resolve the conflict. CONCLUSION: There is a lack of explicit normative advice in the existing literature regarding the responsibilities of pharmacists selling complementary medicines. This review identifies the need to develop a detailed practice-specific ethical framework to guide pharmacists regarding their responsibilities when selling complementary medicines.

Building compassion literacy: Enabling care in primary health care nursing.

This paper introduces the concept of compassion literacy and discusses its place in nursing within the general practice setting. Compassion literacy is a valuable competency for sustaining the delivery of high quality care. Being compassion literate enables practice nurses to provide compassionate care to their patients and to recognise factors that may constrain this. A compassion literate practice nurse may be more protected from compassion fatigue and its negative consequences. Understanding how to enable self-compassion and how to support the delivery of compassionate care within the primary care team can enhance the care experienced by the patient while improving the positive engagement and satisfaction of the health professionals. The capacity to deliver compassionate care can be depleted by the day-to-day demands of the clinical setting. Compassion literacy enables the replenishing of compassion, but the development of compassion literacy can be curtailed by personal and workplace barriers. This paper articulates why compassion literacy should be an integral aspect of practice nursing and considers strategies for enabling compassion literacy to develop and thrive within the workplace environment. Compassion literacy is also a valuable opportunity for practice nurses to demonstrate their key role within the multidisciplinary team of general practice, directly enhancing the quality of the care delivered.

Incidence, duration and cost of futile treatment in end-of-life hospital admissions to three Australian public-sector tertiary hospitals: a retrospective multicentre cohort study.

OBJECTIVES: To estimate the incidence, duration and cost of futile treatment for end-of-life hospital admissions. DESIGN: Retrospective multicentre cohort study involving a clinical audit of hospital admissions. SETTING: Three Australian public-sector tertiary hospitals. PARTICIPANTS: Adult patients who died while admitted to one of the study hospitals over a 6-month period in 2012. MAIN OUTCOME MEASURES: Incidences of futile treatment among end-of-life admissions; length of stay in both ward and intensive care settings for the duration that patients received futile treatments; health system costs associated with futile treatments; monetary valuation of bed days associated with futile treatment. RESULTS: The incidence rate of futile treatment in end-of-life admissions was 12.1% across the three study hospitals (range 6.0%-19.6%). For admissions involving futile treatment, the mean length of stay following the onset of futile treatment was 15 days, with 5.25 of these days in the intensive care unit. The cost associated with futile bed days was estimated to be $AA12.4 million for the three study hospitals using health system costs, and $A988 000 when using a decision maker's willingness to pay for bed days. This was extrapolated to an annual national health system cost of $A153.1 million and a decision maker's willingness to pay of $A12.3 million. CONCLUSIONS: The incidence rate and cost of futile treatment in end-of-life admissions varied between hospitals. The overall impact was substantial in terms of both the bed days and cost incurred. An increased awareness of these economic costs may generate support for interventions designed to reduce futile treatments. We did not include emotional hardship or pain and suffering, which represent additional costs.

Delivering compassionate care in intensive care units: nurses' perceptions of enablers and barriers.

BACKGROUND: Compassion is core to nursing practice. Nurses' expression of compassion is a complex interaction informed by the nurse, the patient and the practice environment. AIM: The aim of this study was to identify personal, professional and organizational factors, intensive care nurses, in a major metropolitan facility in Australia, identified as enabling or disabling them to be compassionate. DESIGN: Intensive care nurses (n = 171) reflected on their experiences during 'compassion cafés' conducted in 2015. METHOD: Qualitative, reflexive methods were used to explore ICU nurses' perceptions of enablers and barriers. Nurses documented their perceptions, which were thematically analysed. Meanings were subsequently verified with participants. RESULTS: The findings identified multiple factors both inside and outside the workplace that constrained or enabled nurses' ability to be compassionate. Two main factors inside the workplace were culture of the team, in particular, support from colleagues and congruency in work practices and decision-making, and connections with patients and families. Outside the workplace, nurses were influenced by their values about care and lifestyle factors such as family demands. CONCLUSIONS: Nurses capacity to be compassionate is a complex interplay between nursing knowledge and expectations, organizational structures and lifestyle factors. IMPLICATIONS: The responsibility for 'compassionate' care is a shared one. Nurses need to be cognizant of factors that are enabling or inhibiting their ability to be compassionate. Healthcare leaders have a responsibility to provide structural support (staffing, education and space) that assist nurses to deliver compassionate care and where appropriate cater for nurses needs so that they are better able to be compassionate.

Reasons doctors provide futile treatment at the end of life: a qualitative study.

OBJECTIVE: Futile treatment, which by definition cannot benefit a patient, is undesirable. This research investigated why doctors believe that treatment that they consider to be futile is sometimes provided at the end of a patient's life. DESIGN: Semistructured in-depth interviews. SETTING: Three large tertiary public hospitals in Brisbane, Australia. PARTICIPANTS: 96 doctors from emergency, intensive care, palliative care, oncology, renal medicine, internal medicine, respiratory medicine, surgery, cardiology, geriatric medicine and medical administration departments. Participants were recruited using purposive maximum variation sampling. RESULTS: Doctors attributed the provision of futile treatment to a wide range of inter-related factors. One was the characteristics of treating doctors, including their orientation towards curative treatment, discomfort or inexperience with death and dying, concerns about legal risk and poor communication skills. Second, the attributes of the patient and family, including their requests or demands for further treatment, prognostic uncertainty and lack of information about patient wishes. Third, there were hospital factors including a high degree of specialisation, the availability of routine tests and interventions, and organisational barriers to diverting a patient from a curative to a palliative pathway. Doctors nominated family or patient request and doctors being locked into a curative role as the main reasons for futile care. CONCLUSIONS: Doctors believe that a range of factors contribute to the provision of futile treatment. A combination of strategies is necessary to reduce futile treatment, including better training for doctors who treat patients at the end of life, educating the community about the limits of medicine and the need to plan for death and dying, and structural reform at the hospital level.

What does "futility" mean? An empirical study of doctors' perceptions.

OBJECTIVE: To investigate how doctors define and use the terms "futility" and "futile treatment" in end-of-life care. DESIGN, SETTING, PARTICIPANTS: A qualitative study using semi-structured interviews with 96 doctors from a range of specialties which treat adults at the end of life. Doctors were recruited from three large Brisbane teaching hospitals and were interviewed between May and July 2013. RESULTS: Doctors' conceptions of futility focused on the quality and prospect of patient benefit. Aspects of benefit included physiological effect, weighing benefits and burdens, and quantity and quality of life. Quality and length of life were linked, but many doctors discussed instances in which benefit was determined by quality of life alone. Most described assessing the prospects of achieving patient benefit as a subjective exercise. Despite a broad conceptual consensus about what futility means, doctors noted variability in how the concept was applied in clinical decision making. More than half the doctors also identified treatment that is futile but nevertheless justified, such as short term treatment that supports the family of a dying person. CONCLUSIONS: There is an overwhelming preference for a qualitative approach to assessing futility, which inevitably involves variability in clinical decision making. Patient benefit is at the heart of doctors' definitions of futility. Determining patient benefit requires discussing with patients and their families their values and goals as well as the burdens and benefits of further treatment.

Recognizing the dialectic of compassionate care in the workplace: feedback from nurse educators.

Compassionate care and compassion fatigue affects managers, clinicians, and patients and is gaining international recognition. Using the café methodology as a structure and nurse educators as participants, a compassion dialectic between the psychological intent of the nurse to be compassionate and a system designed on maximizing throughput, with the least inputs possible is identified. Our findings indicate that the café in itself is not sufficient to enable experienced educators to take responsibility for compassionate care, but the café methodology opens the space for the important steps of naming the problem, recognizing its dialectical nature, deflecting blame for compassion fatigue away from individuals, and balancing the responsibility for compassion across the spectrum of elements that enable care to take place.

Understanding compassion literacy in nursing through a clinical compassion cafe.

This article presents a method of reconnecting and reaffirming with nurses the importance of compassion in health care by using a clinical compassion cafe, which describes nine steps that provide a forum to reaffirm clinicians' core values. This process has the potential to engage clinical staff in a different modality removed from the usual didactic approaches.

Autonomy versus futility? Barriers to good clinical practice in end-of-life care: a Queensland case.

Findings from a Queensland coronial inquest highlight the complex clinical, ethical and legal issues that arise in end-of-life care when clinicians and family members disagree about a diagnosis of clinical futility. The tension between the law and best medical practice is highlighted in this case, as doctors are compelled to seek family consent to not commence a futile intervention. Good communication between doctors and families, as well as community and professional education, is essential to resolve tensions that can arise when there is disagreement about treatment at the end of life.

Emergency medicine and futile care: Taking the road less travelled.

Debate around medical futility has produced a vast literature that continues to grow. Largely absent from the broader literature is the role of emergency medicine in either starting measures that prove to be futile, withholding treatment or starting the end of life communication process with patients and families. In this discussion we review the status of the futility debate in general, identify some of the perceived barriers in managing futile care in the ED including the ethical and legal issues, and establish the contribution of emergency medicine in this important debate. We conclude that emergency physicians have the clinical ability and the legal and moral standing to resist providing futile treatment. In these situations they can take a different path that focuses on comfort care thereby initiating the process of the much sought after 'good death'.

Compliance, normality, and the patient on peritoneal dialysis.

Monitoring and enhancing patient compliance with peritoneal dialysis (PD) is a recurring and problematic theme in the renal literature. A growing body of literature also argues that a failure to understand the patient's perspective of compliance may be contributing to these problems. The aim of this study was to understand the concept of compliance with PD from the patient's perspective. Using the case study approach recommended by Stake (1995), five patients on PD consented to in-depth interviews that explored the meaning of compliance in the context of PD treatment and lifestyle regimens recommended by health professionals. Participants also discussed factors that influenced their choices to follow, disregard, or refine these regimens. Results indicate that health professionals acting in alignment with individual patient needs and wishes, and demonstrating an awareness of the constraints under which patients operate and the strengths they bring to their treatment, may be the most significant issues to consider with respect to definitions of PD compliance and the development of related compliance interventions. Aspects of compliance that promoted relative normality were also important to the participants in this study and tended to result in greater concordance with health professionals' advice.

Moral stress, moral climate and moral sensitivity among psychiatric professionals.

The aim of the present study was to investigate the association between work-related moral stress, moral climate and moral sensitivity in mental health nursing. By means of the three scales Hospital Ethical Climate Survey, Moral Sensitivity Questionnaire and Work-Related Moral Stress, 49 participants' experiences were assessed. The results of linear regression analysis indicated that moral stress was determined to a degree by the work place's moral climate as well as by two aspects of the mental health staff's moral sensitivity. The nurses' experience of 'moral burden' or 'moral support' increased or decreased their experience of moral stress. Their work-related moral stress was determined by the job-associated moral climate and two aspects of moral sensitivity. Our findings showed an association between three concepts: moral sensitivity, moral climate and moral stress. Despite being a small study, the findings seem relevant for future research leading to theory development and conceptual clarity. We suggest that more attention be given to methodological issues and developing designs that allow for comparative research in other disciplines, as well as in-depth knowledge of moral agency.